This case study is about an unfortunate event at an MRI facility involving young Michael Colombini, who died as a result of lethal impact on his skull from an incident in the MRI room. Michael’s death could have been avoided should precautionary measures be prioritized. In this case study, the identified sources of human factors problems, its problems as well as the proposed solutions to overcome the problems will be discussed. The first identified source of problem is the workplace design of the MRI room. As stated in the case description, there was no microphone in the MRI room to enable communication between the anesthesiologist and the technologist in the console room. Here, communication is hindered and the anesthesiologist had to resort …show more content…
Wickens, Lee, Liu and Gordon-Becker (2014) defined human error as the “inappropriate human behavior that lowers levels of system effectiveness or safety”. Human error consists of mistake, which is the intended action that turned out to be inappropriate; slip, which is the unintended incorrect act; and lapse, the omission of nonintentional errors (Wickens, Lee, Liu & Gordon-Becker, 2014). There are various instances of human error demonstrated in the case description including, the nurse entering the MRI room with the oxygen tank (mistake), failure to check the level of oxygen in the tank (lapse) and the oxygen tank accidentally flying over to Michael’s head …show more content…
The oxygen tank in the case description was not equipped with an oxygen level indicator. An indicator is important to inform the operator about the current level of oxygen which will allow the prompt response in changing the oxygen tank if it indicates a low level of oxygen. With the absence of an oxygen level indicator along with the failure of checking the oxygen level in the tank, the personnel were not aware about the low level of oxygen in the tank. Next, we will discuss the problems identified in the case study. The first problem is design deficiency especially in the MRI room and on the oxygen tank. As explained previously, there is poor communication in the MRI room due to the absence of microphone to inform the technologist in the console room about the existing problem. The oxygen tank meanwhile did not have a proper indication panel that informs the state of the oxygen level in the tank. Design deficiency is a major problem because in a state of inadequacy, needed materials for the safety and optimal environment cannot be
(3 nursing, 2015). Communication is one of the most important factors for working in the ambulance service, it provides knowledge and understanding, and it also allows you to connect with your patients and vice versa. Communication between health care works in paramount, anything can be misconstrued. Information that is not transmitted correctly the message is unclear and the message gets miss read, this could cause endless issues for staff and patents. Or sometimes things can be misinterpreted. This is when accidents can occur and my case study is based on lace of communication between staff and
The patient presented with common signs of compartmental syndrome. The interventions suggested to the staff at the hospital were not fully completed. The interventions given during the case presentation consisted of assessing the six Ps, swelling, and vital signs. I took the vital signs of the patient and the nurse recorded them in their system. The patient’s blood pressure was not within normal limits, so the blood pressure completed manually. The manual blood pressure was still elevated. An increase in blood pressure can indicate pain, swelling, and impaired blood flow to the extremities. When I was with the nurse, she sent the patient for an x-ray. Furthermore, the nurse should have then assessed what the patient has been doing and done education with the patient to elevate the leg above his heart. Many people do not know the scientific rationale and positioning of elevating the extremity above the heart. The nurse should have also assessed the patients expectation of pain relief, since his current medication (Ibuprofen) was not working to his expectations. This is when we left the floor; therefore, I was not able to discuss the patient care with the nurse. The nurse simply asked the patient about some of the six Ps of compartmental syndrome and did not complete the assess...
I have been aware of medical errors for some time now. While in nursing school I have heard many stories from classmates and instructors of instances where people they knew, or loved ones had been either harmed or died because of a medical error. I have had experiences with medical errors. When I was in the hospital for the birth of my first child, the nurse that came to change out my IV bag did not check the
Hospital medical errors can involve medicines (e.g., wrong drug, wrong dose, bad combination), an inaccurate or incomplete diagnosis, equipment malfunction, surgical mistakes, or laboratory errors. High medical error rates with serious consequences occurs in intensive care units, operating rooms, and emergency departments; but, serious errors that harmed patients may have prevented or minimized. Understand the nature of the error
In our organization we have had many revisions to our safety process. Originally, it was at our hospital that the 1996 well known “Willy King” incident, about the amputation of the “wrong” leg occurred. As a response to the incident, we were required to develop a root-cause-analysis and develop a plan to avoid similar situations in the future. We were one of the first hospitals to establish a “safety process” in the surgical environment. Through inter-disciplinary collaborati...
After review of the timeline of the events surrounding Mr. B, there are several causative factors that led to this sentinel event. These are inappropriate staffing, inability to identify trends of deterioration, policy for conscious sedation was not followed, inadequate observation and monitoring, failure to respond to alarms, inadequate home medication evaluation, medication dosing, appropriate medication administration times, and failure to start cardiopulmonary resuscitation in a timely manner.
Human factors are derived from construction and adapted to a system of development in health care by carefully examining the relationship between people, environment, and technology. The consideration of human factors acknowledges the capability or inability to perform a precise task while executing multiple functions at once. Human factors provide an organized method to prevent errors and create exceptional efficiency. Careful attention must be exercised in all levels of care such as the physical, social, and external environment. It is also vital to carefully consider the type of work completed and the quality of performance. Applying human factors to the structure of healthcare can help reduce risks and improve outcomes for patients. This includes physical, behavioral, and cognitive performance which is important to a successful health care system that can prevent errors. A well-designed health care system can anticipate errors before they occur and not after the mistake has been committed. A culture of safety in nursing demands strong leadership that pays attention to variations in workloads, preventing interruptions at work, promotes communication and courtesy for everyone involved. Implementing a structure of human factors will guide research and provide a better understanding of a nurse’s complicated work environment. Nurses today are face challenges that affect patient safety such as heavy workloads, distractions, multiple tasks, and inadequate staffing. Poor communication and failure to comply with proper protocols can also adversely affect patient safety. Understanding human factors can help nurses prevent errors and improve quality of care. In order to standardize care the crew resource management program was
One of them is the Crew Resource Management (CRM) present in the Aviation field that experts have come up. It is safety training that focuses team management that is very effective. The CRM programs essentially educate the crew members on how human competency may be limited. The operational perceptions emphasized include examination, promotion, seeking information related to operations, communicating projected exploits, decision-making and conflict resolution. The improvements on the safety records, which were observed after the implementation of this new safety training on commercial aviation, were tremendous compared to the previous record where 70 percent of the commercial flight accidents were as a result poor communication among crew members. Secondly, there is the Kaiser Permanente, SABR (Situation, Background, Assessment, and Recommendation) Tool 2002 which reveals that indeed doctors and nurses more often than not have different communication styles partly owing to their training. Physicians are taught to be concise while nurses to be able to vividly describe medical conditions. SABR was created by a physician co-coordinator of the informatics at the Kaiser Permanente, Michael Leonard together with his colleagues and it has been used vastly in the healthcare systems, one of them being the Kaiser Permanente. It provides a framework of communication between medical
Every hospital is committed to ensuring that their patients in stroke rehabilitation wards and other facilities are safe from any form of harm that may occur as a result of the health care providers’ negligence. Firstly, every hospital integrates quality and safety approaches into its everyday’s operations to promote and enhance the safety and quality of its environment and services respectively (Garban, 2011). This is usually complemented by other strategies meant for enhancing organizational knowledge to improve efficiency and overall productivity. Some hospitals provide further training to their health care personnel to ensure that they efficiently incorpor...
As stated in previously, oxygen tank 2 was damaged during a removal procedure, but was deemed safe for use after initial inspection. When the system was modified to accept the 5 volt source
In the provision of a high quality care, many factors influence the way it is provided; however, IC is crucial. A healthy work environment would result from open communication among the staff, it would increase the employees and patients’ level of satisfaction and sense of well-being. Good communication is the cornerstone for the IC, it is a complex process which requires to develop some skills to learn how to transmit some information. One of the most common factors leading to medical errors, are due to miscommunication, sometimes because the message is not clearly sent, and others because it is not clearly received or it is misunderstood (Danna, 2015). In terms of communication non-verbal communication must be taken into consideration as well; body language, facial expressions, use of space, and touch, entail conscious or unconscious movements and gestures, also impacts the communication among the staff and
The rate of errors and situations are seen as chances for improvement. A great degree of preventable adversative events and medical faults happen. They cause injury to patients and their loved ones. Events are possibly able to occur in all types of settings. Innovations and strategies have been created to identify hazards to progress patient and staff safety. Nurses are dominant to providing an atmosphere and values of safety. As an outcome, nurses are becoming safety leaders in the healthcare environment(Utrich&Kear,
Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency coordination task force with the help of government agencies. These government agencies are responsible for making health pol-icies regarding patient safety to which every HCO must follow (Schulman & Kim, 2000).
The health care is extremely important to society because without health care it would not be possible for individuals to remain healthy. The health care administers care, treats, and diagnoses millions of individual’s everyday from newborn to fatal illness patients. The health care consists of hospitals, outpatient care, doctors, employees, and nurses. Within the health care there are always changes occurring because of advance technology and without advance technology the health care would not be as successful as it is today. Technology has played a big role in the health care and will continue in the coming years with new methods and procedures of diagnosis and treatment to help safe lives of the American people. However, with plenty of advance technology the health care still manages to make an excessive amount of medical errors. Health care organizations face many issues and these issues have a negative impact on the health care system. There are different ways medical errors can occur within the health care. Medical errors are mistakes that are made by health care providers with no intention of harming patients. These errors rang from communication error, surgical error, manufacture error, diagnostic error, and wrong medication error. There are hundreds of thousands of patients that die every year due to medical error. With medical errors on the rise it has caused the United States to be the third leading cause of death. (Allen.M, 2013) Throughout the United States there are many issues the he...
It is shocking to know that every year 98000 patients die from medical errors that can be prevented(Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.), 2000). Medical errors are not a new issue in our healthcare system; these have been around for a long time. Hospitals have been trying to improve quality care and patients safety by implementing different strategies to prevent and reduce medical errors for past thirty years. Medical errors are the third leading cause of death after heart disease and cancer in America (Allen, 2013). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Andel, Davidow, Hollander, & Moreno, 2012).